Laserfiche WebLink
[�Y Zo2 <br /> IED PROGRAM CONSOLIDATED FO j �M <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FITiYa OSURE 4aa. <br /> (Check one item only) El3.RENEWAL PERMIT ® 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PER I //LL�_�i <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. <br /> 3 FACILITY ID# <br /> ('4eirUse 0,l <br /> ) <br /> BUSINESS NAME(Svoeo FACMITYNAM or DBA-Doing Busimss As) <br /> Spirit Gasoline P NMENT,q�H <br /> FA <br /> BUSINESS SITE ADDRESS 103. CITY CES 104. <br /> 1250 North Wilson Way Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> ARCO#9600-BP West Coast Products,LLC (714) 670-5040 <br /> MAILING ADDRESS 409. <br /> PO Box 6038 <br /> CITY 410. 1 STATE 411, ZIP CODE 412. <br /> Artesia CA 95205 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1. PHONE 428-2 <br /> Jo inder Lal (209) 547-1700 <br /> MAILING ADDRESS 428-3 <br /> 840 Dupont Drive <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> Stockton CA 95210 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Jo finder Lal (209) 547-1700 <br /> MAILING ADDRESS 416. <br /> 840 Dupont Drive <br /> CITY 41/. STATE 418, ZIP CODE 419. <br /> Stockton <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 4 1 1 1 4 1 6 1 5 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: El 1.FACILITY OWNER [14.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> -�f 18 2. - 2 C,, - N Z (209) 547-1700 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Jo finder La) Owner/Operator <br /> UPCF UST-A Rev.(12/2007) <br />